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Chapter 11
INJURIES TO THE SHOULDER REGION
Anatomy Review. The shoulder bones consist of the shoulder girdle (clavicle and scapula) and the
humerus. The head of the humerus and the glenoid fossa form the glenohumeral (GH) joint
(shoulder joint), which receives additional support from the glenoid labrum. The shoulder region
also includes the acromioclavicular (AC) joint and the sternoclavicular (SC) joint.
A. Each of these joints is held together by ligaments and joint capsules that provide stability
and allow movement, which is quite limited. Any limitation from injury to the shoulder indirectly
affects the GH joint. Shoulder girdle muscles are the levator scapulae, trapezius, rhomboids,
subclavius, pectoralis minor, and serratus anterior. (See Figure 11.4 on page 153 and refer to Time
Out 1.1 on page 154.)
B. The muscles that act on the GH joint include the pectoralis major, latissimus dorsi,
deltoid, teres major, rotator cuff muscles, and coracobrachialis. The GH joint can move in virtually
every direction.
C. A large amount of soft tissue covers the shoulder girdle and GH joint, somewhat
protecting these regions from external blows. The AC and SC joints lie just under the skin and are
vulnerable to injury, even in muscular athletes.
D. The blood supply to the upper extremity originates from branches of the subclavian
artery. In the axillary region, the subclavian artery becomes the axillary artery. In the upper arm, the
axillary artery becomes the brachial artery, which splits just distal to the elbow into the radial and
ulnar arteries that extend into the forearm and hand (refer to Figure 11.6 on page 156).
E. The major nerves of this region come from the group of nerves known as the brachial
plexus (see Figure 11.7 on page 156). The brachial plexus originates from the ventral primary
divisions of the fifth through eighth cervical nerves and the first thoracic nerve.
I. Common Sports Injuries. Injuries to the shoulder region frequently occur in many sports. Injuries
to the AC and the GH joints are common in wrestling; throwing and swinging sports can result in
overuse injuries to the rotator cuff muscles that act on the GH joint. Cycling and skating sports
result in a large number of fractures of the clavicle brought about by falls.
Injuries of this region can be either acute or chronic. Sports involving heavy contact or
collisions yield more acute injuries; those requiring repeated movements produce more chronic
injuries.
A. Skeletal Injuries.
1. Fractured Clavicle. Fractured clavicle is the most common fracture of the region.
Such fractures can result from direct blows to the bone, but the majority are the result of falls that
transmit the force to the clavicle either through the arm or shoulder.
a. Most clavicle fractures occur about mid-shaft.
b. In the adolescent, another type of clavicular fracture can occur that is
known as the greenstick fracture. This type of fracture involves a cracking, splintering type of injury
to immature bone.
c. Clavicle fractures are potentially dangerous, but the majority cause few
complications.
d. Typical signs and symptoms include swelling and/or deformity at the site
of fracture, discoloration at the site, a broken bone end may project through the skin, and the athlete
reports that a snap or pop was heard or felt. Additionally, the athlete holds the arm on the affected
side to relieve pressure on the shoulder girdle.
e. First aid includes treatment for possible shock, application of a sling and
swathe bandage (see Figure 11.9 on page 156), and application of sterile dressings on any
associated wounds.
f. Arrange for transport to a medical facility.
2. Fractured Scapula. This is a relatively uncommon injury to the shoulder region
that generally results from direct blows to the shoulder region.
a. The signs and symptoms are less clear than for fractures of the clavicle and
include history of severe blow to the shoulder region, followed immediately by considerable pain
and functional loss.
1) An athlete with such a history and symptoms should be referred to
a physician for evaluation.
B. Soft-Tissue Injuries. The GH and AC joints are the most injured in the shoulder region.
1. Acromioclavicular Joint Injuries. The AC joint is located on the lateral superior
surface of the shoulder, just under the skin. This articulation is supported by the AC ligaments and
contains an intra-articular cartilaginous disk. Additional support is provided by the CC ligament
(refer to Figure 11.2 on page 152).
a. The typical mechanism of injury to the AC joint is a downward blow to the
outer end of the clavicle. Another possible mechanism is a fall on an outstretched arm that transmits
the force up the extremity. Both cases result in varying degrees of ligament damage. The severity of
the injury is graded based on the amount of damage to specific ligaments, but any injury can be
classified into three categories:
1) First degree involves no significant damage; all ligaments are
intact.
2) Second degree involves relatively severe damage (tearing of the
ligaments), but there is no abnormal movement and the clavicle is in the normal position.
3) Third degree involves complete rupture of AC ligament with an
intact CC ligament (refer to Figure 11.10 on page 157), or complete rupture of AC and CC
ligaments (refer to Figure 11.11 on page 157).
b. Signs and symptoms of first- and second-degree sprains include mild
swelling, point tenderness, and discoloration around the AC joint.
1) Any movement of the shoulder region will be painful.
2) In a third-degree sprain, there is considerable deformity in the
region of the AC ligament. If both the AC and CC ligaments have ruptured, there will be total
displacement of the clavicle.
3) The athlete may report having felt a snap or heard a pop.
c. First aid involves immediate application of ice and compression using a
bag of crushed ice over the AC joint and securing it with an elastic bandage wrapped in a figureeight configuration.
1) After the ice and compression is in place, apply a standard slingand-swathe bandage.
2) Refer immediately to a medical doctor. In the event of severe
injury, arrange for transport and treat for shock.
d. Non-surgical approaches to treatment may be just as effective as surgical
ones.
2. Glenohumeral Joint Injuries. This joint consists of the relatively large humeral
head opposing the shallow glenoid fossa of the scapula. The GH joint has a great deal of mobility
but is unstable. Major soft-tissue structures of the GH joint include the capsular ligament and the
coracohumeral ligament.
a. The typical mechanism of injury to the GH joint is having the arm
abducted and externally rotated. This mechanism stresses the GH joint capsule and associated
ligaments beyond their capacity.
b. The most common type of GH joint dislocation is known as the anterior
dislocation, which may be a subluxation or complete dislocation.
c. Signs and symptoms include shoulder joint deformity, the normal contour
of the shoulder is lost and it slopes down; abnormally long arm on affected side; the humeral head
will be palpable with the axilla.
1) The athlete will support the arm on the affected side; the affected
arm will be slightly abducted at the shoulder and flexed at the elbow.
2) The athlete will resist all efforts to passively or actively move the
GH joint.
d. In cases of subluxation, the GH joint may appear normal, however,
movement will be painful and the joint may be point tender.
e. First aid care includes immediate application of ice and compression with a
rolled towel placed in the axilla. Place the bag of crushed ice on the front and back of the shoulder
joint and secure with an elastic wrap in a figure-eight configuration.
1) After the ice and compression is in place, apply a standard slingand-swathe bandage.
2) Refer immediately to a medical doctor. In the event of severe
injury, arrange for transport and treat for shock.
f. GH joint injuries can become chronic; 85% to 90% of all traumatic anterior
GH injuries recur. In severe cases, surgical reconstructive procedures may be needed.
3. Sternoclavicular Joint Injuries. The SC joint is formed by the union of the
proximal end of the clavicle and the manubrium of the sternum. The SC joint is supported by
several ligaments (see Figure 11.3 on page 152) that include the joint capsule, the SC ligaments, the
interclavicular and costoclavicular ligaments, and an articular disk within the joint.
a. Injuries to the SC joint are far fewer than to either the AC or GH joints. A
sprain to the SC joint may range in severity from minor (no ligament tearing) to a complete rupture
of all supporting ligaments.
b. The mechanism of injury involves an external blow to the shoulder
resulting in a dislocation of the proximal clavicle, most commonly with the bone moving anteriorly
and superiorly. Such dislocations cause few additional problems and are easily treated.
1) A rare but potentially dangerous form of this injury is a posterior
SC dislocation, which can put pressure on soft-tissue structures in the region, such as blood vessels
or even the esophagus and/or trachea.
c. Signs and symptoms include gross deformity of the SC joint (second- and
third-degree sprains), swelling, limited movement of the shoulder due to pain within the SC joint.
1) The athlete will often report a snapping sound or experiencing a
tearing sensation at the SC joint.
2) The athlete typically holds the arm on the affected side close to the
body and the head/neck region may be tilted or flexed toward the injured shoulder.
d. First aid care includes application of ice and compression achieved with a
bag of crushed ice secured by an elastic wrap in a figure-eight configuration. Do not put pressure
over the airway when wrapping the shoulder.
1) Place the arm of the affected shoulder in a standard sling-andswathe bandage.
2) In cases of severe soft-tissue damage, treat for shock.
e. Treatment of most SC joint injuries is conservative. Eventually, a sound
rehabilitation exercise program prescribed by a sports medicine professional will be helpful.
4. Strains of the Shoulder Region. Any muscles of the shoulder region can suffer a
strain. Perhaps the most common strain involves the rotator cuff.
a. Rotator Cuff. The muscles of the rotator cuff contribute to abduction and
rotation of the GH joint.
1) The throwing process has been described as a five-phase process of
windup, cocking, acceleration, release, and follow-through.
2) The cocking phase involves pulling the throwing arm into an
abducted and externally rotated position at the GH joint, incorporating a concentric contraction of
several rotator cuff muscles.
3) During the follow-through phase, several rotator cuff muscles are
contracting eccentrically to slow the arm down; this is when most rotator strains occur.
4) Strains to the rotator cuff are normally the result of overuse and
develop slowly over a period of weeks or months.
5) Athletes involved in throwing or swinging sports should have a
properly designed rotator cuff conditioning program and should warm up the throwing arm
properly.
6) Errors in the execution of a throw or swing can contribute to an
overuse injury. Teaching correct technique reduces the chances of such injuries.
7) Signs and symptoms of injury include pain within the shoulder,
especially during the follow-through phase; difficulty in bringing the arm up and back during the
cocking phase; pain and stiffness within the shoulder region 12 to 24 hours after throwing or
swinging; and point tenderness around the region of the humeral head that appears to be deep in the
deltoid muscle.
8) First aid care must take into consideration that overuse injuries are
difficult to treat effectively without a thorough medical evaluation. When symptoms occur, the
application of ice and compression may be helpful. In most cases, the athlete will report repeated
bouts of symptoms for weeks, even months. Therefore, medical referral is necessary.
b. Glenohumeral Joint-Related Impingement Syndrome. A syndrome is
defined as “a number of symptoms occurring together and characterizing a specific disease.”
Impingement syndrome of the shoulder occurs when a soft-tissue structure such as a bursa or tendon
is squeezed between moving joint structures, resulting in irritation and pain.
1) In cases affecting the GH joint, the most common impingement
occurs to the tendon of the supraspinatus muscle as it passes across the top of the joint en route to
its insertion.
2) Any condition that decreases the size of the subacromial space may
result in an impingement syndrome. (Refer to Figure 11.16 on page 163 for an illustration of the
anatomy of this region.)
3) Athletes in sports that require an emphasis on arm movements
above the shoulder are at a higher risk of impingement syndrome than athletes in sports that do not
require such movements.
4) Signs and symptoms include pain when the GH joint is abducted
and externally rotated in conjunction with loss of strength, pain whenever the arm is abducted
beyond 80° to 90°, nocturnal pain, and pain felt deep within the shoulder.
5) First aid care is not needed, as they tend to develop over a long
time period. Any athlete complaining of the above signs and symptoms should be referred for a
complete medical evaluation.
6) Treatment consists of rest, anti-inflammatory drugs, and physical
therapy. In severe cases, surgery may be indicated.
c. Biceps Tendon Problems. The GH joint includes the tendon of the long
head of the biceps brachii muscle. The tendon passes into the joint capsule and is surrounded by the
synovium of the GH joint. The tendon of the short head of the biceps brachii muscle derives from
the coracoid process, but the tendon remains separate from the GH joint.
1) The tendon of the long head of the biceps brachii can suffer an
impingement syndrome if it is compressed within the subacromial space.
2) The symptoms are similar to those of impingement of the
supraspinatus tendon.
3) Athletes who are at risk for this injury include those involved in
sports that place an emphasis on repetitive overhead movements with the arms.
4) Another problem related to the long head tendon of the biceps
brachii is tendinitis that may lead to a subluxation of the tendon from the bicipital groove. This
develops slowly over a period of weeks or months. As the tendon enlarges as a result of
inflammation, it becomes less stable in the groove, where it is held by the transverse humeral
ligament.
5) In chronic cases, a sudden violent force such as is generated by
throwing may cause the tendon to subluxate out of the groove, stretching and tearing the ligament.
6) Signs and symptoms of biceps tendon problems include painful
abduction of the shoulder joint; pain in the shoulder joint when the athlete supinates the forearm
against resistance; and the athlete may note a popping or snapping sensation when flexing and
supinating the forearm against resistance.
7) First aid care is not a concern because such injuries develop over
time and fall into the category of a chronic injury. If the athlete should subluxate the biceps tendon
from the bicipital groove, immediate application of ice and compression is recommended. Longterm care includes rest, anti-inflammatories, and gradually progressive rehabilitation exercise. If
symptoms persist, surgery may be necessary.
d. Contusions of the Shoulder Region. External blows to the shoulder region
often happen in many sports. The GH joint is well protected by muscles that cross the joint, while
the nearby AC joint is totally exposed to external blows. If the athlete sustains a contusion to the
joint the result can be an extremely painful condition known as a shoulder pointer.
1) Signs and symptoms include history of a recent blow to the
shoulder, associated with pain and decreased ROM; spasm if muscle tissue is involved; and
discoloration and swelling, especially over bony areas such as the AC joint.
2) First aid care includes immediate application of ice and
compression. In cases of severe pain, apply an arm sling to relieve stress on the shoulder region.
3) If significant swelling persists for more than 72 hours, refer the
athlete to a physician. In some cases the AC ligament may have sustained a sprain.
REVIEW QUESTIONS
1. Which two bones make up the shoulder girdle?
Answer: The clavicle and the scapula
Page: 152
2. To what structure is the glenoid labrum attached?
Answer: The glenoid fossa
Page: 152
3. Which one of the following arteries provides the blood supply to the shoulder region and upper
extremity?
a.) Common iliac
b.) Ulnar
c.) Internal carotid
d.) Subclavian
e.) Axillary
Answer: D
Page: 153
4. Which one of the following is the correct derivation of the brachial plexus?
a.) C-5/T-2
b.) C-3/T-1
c.) C-1/T-5
d.) C-1/T-1
e.) C-5/T-1
Answer: E
Page: 153
5. List the four muscles of the rotator cuff group and identify one action common to each muscle.
Answer:
1.) Infraspinatus
2.) Supraspinatus
3.) Teres minor
4.) Subscapularis
Page: 155
6. List four signs and/or symptoms of a fractured clavicle.
Answer:
1.) Swelling and/or deformity of the clavicle
2.) Discoloration at the site of the fracture
3.) Possible broken bone end projecting though the skin
4.) Athlete reporting that a snap or pop was felt or heard
5.) Athlete holding the arm on the affected side in order to relieve pressure on the shoulder girdle
Page: 155
7. Describe and/or demonstrate the appropriate first aid procedure for a fractured clavicle.
Answer:
1.) Treat for possible shock
2.) Carefully apply a sling-and-swathe bandage
3.) Apply sterile dressings to any related wounds
4.) Arrange for transportation to a medical facility
Page: 156
8. Describe the major ligaments that form the AC joint.
Answer: The synoviated articulation is supported by the superior and inferior AC ligaments.
Additional support to the AC joint is provided by the coracoclavicular ligament, which comprises
the trapezoid and conoid ligaments.
Page: 157
9. Describe briefly the two mechanisms of injury for the AC joint as discussed in the chapter.
Answer: The two mechanisms of injury for the AC joint are a downward blow to the outer end of
the clavicle and a fall forward on an outstretched arm.
Page: 157
10. Describe the common signs and symptoms of AC joint injuries.
Answer:
1.) With first- and second-degree sprains there will be mild swelling with point tenderness and
discoloration around the AC joint.
2.) Any movement of the shoulder region will elicit pain.
3.) With a third-degree sprain there will be significant deformity in the region of the AC ligament.
In the case of ruptures of both the AC and CC ligaments, there will be total displacement of the
clavicle.
4.) The athlete may report having felt a snap or heard a pop.
Page: 158
11. Explain and/or demonstrate the appropriate first aid care for AC joint injuries.
Answer:
1.) Immediately apply ice and compression.
2.) Apply a standard sling-and-swathe bandage.
3. Immediately refer the athlete to a medical facility for further evaluation.
Page: 158
12. List the major ligaments of the GH joint.
Answer: The capsular ligament and the coracohumeral ligament
Page: 158
13. True or False: The most common type of GH joint dislocation is posterior.
Answer: False. The most common type of GH joint dislocation is an anterior dislocation.
Page: 158
14. Describe the common signs and symptoms of a GH joint dislocation.
Answer:
1.) Deformity of the shoulder joint: The normal contour of the shoulder is lost, and it appears to
slope down abnormally.
2.) The arm of the affected side will appear longer than normal.
3.) The head of the humerus will be palpable with the axilla.
4.) The athlete will be supporting the arm on the affected side with the opposite arm; the affected
arm will be slightly abducted at the shoulder and fixed at the elbow.
5.) The athlete will resist all efforts passively or actively to move the GH joint.
Page: 158
15. Explain and/or demonstrate the appropriate first aid treatment of an athlete with a suspected GH
joint dislocation.
Answer:
1.) Immediately apply ice and compression.
2.) Once the ice and compression are in place, apply a standard swing-and-swathe bandage.
3.) Immediately refer the athlete to a medical facility for further evaluation.
4.) Because soft-tissue injury may be extensive, treat for shock.
Page: 158-159
16. Define the condition known as chronic GH subluxation.
Answer: The joint capsule, ligaments, and supporting musculature are often stretched; therefore, as
the athlete continues to participate in stressful activity the joint becomes progressively less stable.
Page: 159
17. Describe the primary ligaments of the SC joint.
Answer: The anterior and posterior SC ligaments and the interclavicular and costoclavicular
ligaments.
Page: 159
18. Describe the common signs and symptoms of injury to this articulation.
Answer:
1.) In most cases there will be gross deformity present at the SC joint.
2.) In all but the least severe cases, swelling will be immediate.
3.) Movement of the entire shoulder girdle will be limited owing to pain within the SC joint.
4.) The athlete will typically report having heard a snapping sound or may have experienced a
tearing sensation at the SC joint.
5.) Note the body position of the athlete, because in this injury the arm may be held close to the
body and head/neck may be tilted/flexed toward the injured shoulder.
Page: 159
19. Explain and/or demonstrate the appropriate first aid treatment of an athlete with a suspected SC
joint injury.
Answer:
1.) Immediately apply ice and compression.
2.) Once the ice and compression are in place, apply a standard swing-and-swathe bandage.
3.) If severe soft-tissue damage, treat for shock.
Page: 160
20. Explain the five phases of an overhand throw and/or swing and give a brief description of the
types of muscle contractions involved in each.
Answer: See explanation on page 160.
Page: 160
21. True or False: The vast majority of strains of the rotator cuff occur during the windup and
cocking phase of the throw and/or swing.
Answer: False. The vast majority of strains of the rotator cuff occur during the follow-through
phase.
Page: 160
22. List several of the signs and symptoms of rotator cuff as described in the chapter.
Answer:
1.) Pain within the shoulder, especially during the follow-through phase of a throw or swing.
2.) Difficulty in bringing the arm up and back during the cocking phase of a throw or swing.
3.) Pain and stiffness within the shoulder region 12-24 hours after a practice or competition that
involved throwing or swinging.
4.) Point tenderness around the region of the humeral head that appears to be deep within the deltoid
muscle.
Page: 161
23. What anatomical structure forms a ceiling for the subacromial space?
Answer: The acromion process and coracoacromial ligament
Page: 161
24. True or False: Athletes involved in sports placing a heavy emphasis on arm movements below
the shoulder level demonstrate a higher incidence of impingement syndromes.
Answer: True
Page: 161
25. List four signs and/or symptoms of impingement syndrome of the GH joint.
Answer:
1.) Pain when the GH joint is abducted and externally rotated in conjunction with loss of strength
2.) Pain whenever the arm is abducted beyond 80 to 90 degrees
3.) Nocturnal pain
4.) Pain felt deep within the shoulder
Page: 161
26. Which one of the following structures (ligaments) holds the biceps (long head) tendon in the
bicipital groove?
a. Annular ligament
b. Medial collateral ligament
c. Capsular ligament
d. Transverse humeral ligament
Answer: D
Page: 163